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Abusayf MM, Liu YC, Han E, Yu ILX, Riau AK, Mehta JS. One-Step Intraoperative Optical Coherence Tomography Guided Tunnel, Mushroom Femtosecond Laser Big Bubble Deep Anterior Lamellar Keratoplasty. Bioengineering (Basel) 2024; 11:639. [PMID: 39061721 PMCID: PMC11273850 DOI: 10.3390/bioengineering11070639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/15/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
The aim of our study is to investigate the feasibility and outcomes of using a femtosecond laser (FSL) platform (Ziemer LDV Z8) for deep anterior lamellar keratoplasty (DALK), enabling the creation of mushroom-shaped graft-host junctions, lamellar cuts, and intrastromal tunnels, to facilitate the big bubble, in one step. We included wet lab experiments on nine porcine eyes to assess the laser accuracy and cuts depth using an anterior segment (AS) OCT. This was followed by an interventional prospective case series on 10 eyes with variant corneal pathologies. The Z8 system, with in-built intraoperative optical coherence tomography (iOCT), guided corneal scans and directed the cuts. ASOCT showed visible mushroom configurations, lamellar cuts, and tunnels. Deviations from the target were 1.6%, 2.6%, and 3.5%. Anterior lamellar removal was easy in all clinical cases, including corneal scarring. The intrastromal tunnel was found at the preset location and the mushroom configuration was acquired. A big bubble was achieved in all cases. Type 1, 2, and 3 bubbles were formed in eight, one, and one case, respectively. We describe a new approach to DALK in which the in-built iOCT-guided FSL enables safe, precise, controlled, and reproducible desired cuts in one step. The preliminary clinical outcomes were favorable.
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Affiliation(s)
- Mohammed M. Abusayf
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
- Cornea and External Eye Disease Service, Singapore National Eye Center, Singapore 168751, Singapore;
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
| | - Yu-Chi Liu
- Cornea and External Eye Disease Service, Singapore National Eye Center, Singapore 168751, Singapore;
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
- Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
| | - Evelina Han
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
| | - Isabelle Lee Xin Yu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
| | - Andri K. Riau
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
- Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
| | - Jodhbir S. Mehta
- Cornea and External Eye Disease Service, Singapore National Eye Center, Singapore 168751, Singapore;
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
- Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
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Gurnani B, Kaur K, Chaudhary S, Kaur RP, Nayak S, Mishra D, Balakrishnan H, Parkash RO, Morya AK, Porwal A. Pediatric corneal transplantation: techniques, challenges, and outcomes. Ther Adv Ophthalmol 2024; 16:25158414241237906. [PMID: 38533487 PMCID: PMC10964464 DOI: 10.1177/25158414241237906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/13/2024] [Indexed: 03/28/2024] Open
Abstract
Pediatric corneal transplant is a highly demanding and technically challenging procedure for the cornea surgeon in today's era. These cases pose unique challenges in clinical and surgical management. The indications of pediatric corneal transplant can be therapeutic, tectonic, optical, and cosmetic. Pediatric patients undergoing corneal transplants are at a high risk of graft infection, failure, rejection, dehiscence, and amblyopia due to young age, robust immune system, increased incidence of trauma, and compliance issues. The other factors contributing to graft failure can be allograft rejection, secondary glaucoma, corneal vascularization, multiple surgeries, vitreous prolapse, and lack of treatment compliance. A successful corneal transplant in children depends on meticulous preoperative evaluation, uneventful surgery, the expertise of a corneal surgeon, and regular and timely postoperative follow-up. Therapeutic and optical penetrating keratoplasty are the most commonly performed transplants in children. However, with the advancements in surgical technique and management protocol, the current focus has shifted toward lamellar keratoplasty. Lamellar keratoplasty offers early visual recovery and potentially fewer complications. Visual rehabilitation through corneal transplant in otherwise blind eyes can be a boon for the children. Recently, keratoprostheses have been promising in children with multiple graft failures. The current review gives insights into epidemiology, etiology, indications, clinical characteristics, investigations, management options, recent advances, and the future of pediatric corneal transplants. As surgical techniques continue to grow and comprehension of pediatric corneal transplants is improving, we can safeguard these eyes with the best possible anatomical and functional outcomes.
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Affiliation(s)
| | - Kirandeep Kaur
- Cataract, Paediatric Ophthalmology and Strabismus, India
- ASG Eye Hospital, Jodhpur, Rajasthan, India
| | | | | | - Swatishree Nayak
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Deepak Mishra
- Regional Institute of Ophthalmology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | | | | | - Arvind Kumar Morya
- Cataract, Glaucoma, Refractive, Squint Paediatric Ophthalmology and Medical Retina Services, Department of Ophthalmology, All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana, India
| | - Amit Porwal
- Head of the Department, Glaucoma Services, Choitram Netralaya, Indore, Madhya Pradesh, India
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Du K, Liu E, Li N, Yuan B, Peng R, Hong J. Comparison of Femtosecond Laser Assistance and Manual Trephination in Deep Anterior Lamellar Keratoplasty in the Treatment of Keratoconus: A Meta-Analysis. Am J Ophthalmol 2023; 256:126-137. [PMID: 37553035 DOI: 10.1016/j.ajo.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE To compare the efficacy and safety of femtosecond laser-assisted deep anterior lamellar keratoplasty (F-DALK) with those of manual-trephination DALK (M-DALK) in treating keratoconus. DESIGN Systematic review and meta-analysis. METHODS Through November 2022, we comprehensively searched PubMed, EMBASE, the Cochrane Library, and 4 Chinese databases. Studies that involved comparisons between F-DALK and M-DALK groups and that reported on relevant efficacy and/or safety parameters were included. Primary outcomes were uncorrected- and corrected-distance visual acuity and intraoperative complication rates. Secondary outcomes were spherical equivalent, topographic astigmatism, refractive cylinder, mean keratometry, endothelial cell density, suture removal time, and postoperative complication rates. These data were analyzed using Cochrane Review Manager software version 5.3. RESULTS This meta-analysis included 9 nonrandomized controlled studies involving 1713 eyes. In eyes treated with F-DALK, corrected-distance visual acuity at 1 to 6 months (weighted mean difference = -0.07 [95% confidence interval {CI} -0.10 to -0.03]; I2 = 0%; P < .001) after surgery was better and intraoperative Descemet membrane perforation occurred less often (odds ratio = 0.53 [95% CI 0.31-0.92]; I2 = 6%; P = .02) than in eyes treated with M-DALK. No clinically significant differences in other outcomes were found among the groups. CONCLUSIONS Both F-DALK and M-DALK are safe and efficacious for patients with keratoconus. Compared with M-DALK, F-DALK can provide better early visual acuity and reduce the intraoperative perforation rate, and its likely improvements to long-term visual quality and endothelial cell preservation warrant further investigation. In addition, the 2 techniques seem to be comparable regarding refractive outcomes and other complications.
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Affiliation(s)
- Kaiyue Du
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Enshuo Liu
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Nan Li
- Peking University Third Hospital (N.L.), Beijing, China
| | - Bowei Yuan
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Rongmei Peng
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Jing Hong
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China.
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Wylęgała A, Roszkowska AM, Kokot J, Dobrowolski D, Wylęgała E. Clinical Evaluation of the Efficacy of Femtosecond Laser-Assisted Anterior Lamellar Keratoplasty. J Clin Med 2023; 12:jcm12031158. [PMID: 36769806 PMCID: PMC9917846 DOI: 10.3390/jcm12031158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND To evaluate the clinical outcome, efficacy, and safety of femtosecond laser-assisted anterior lamellar keratoplasty. MATERIAL AND METHODS In this prospective study, 21 males and 10 females aged from 15 to 62 years (mean 38.5) with different pathologies of the anterior corneal layers were enrolled for anterior lamellar keratoplasty using femtosecond laser VisuMax (Carl Zeiss, Germany). All patients were examined for uncorrected (UCVA) and best-corrected (BCVA) distance and near visual acuity, astigmatism, endothelial cell density, corneal thickness, and intraocular pressure. These examinations were performed before transplantation, at hospital discharge, and after 3 and 12 months. The mean follow-up time was 65.36 ± 28.54 months. RESULTS A statistically significant improvement of both UCVA and BCVA for distance and near vision was registered. BCVA improved from 0.11 preoperatively to 0.168 (p = 0.03), 0.267 (p < 0.01), and 0.472 (p < 0.01) on the hospital discharge day, three months, and 12 months respectively. There were no statistically significant differences in astigmatism, intraocular pressure, endothelial cell density, and corneal pachymetry as compared to preoperative and postoperative values. Six patients (19%) had a graft failure with a rate of 33% at 26 months. CONCLUSIONS Femtosecond laser-assisted anterior lamellar keratoplasty is a safe and effective surgical method, providing satisfactory graft survival rates.
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Affiliation(s)
- Adam Wylęgała
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Faculty of Medical Sciences, Medical University of Silesia, 40-055 Katowice, Poland
- Ophthalmology Department, Railway Hospital, 40-760 Katowice, Poland
- Correspondence:
| | - Anna M. Roszkowska
- Ophthalmology Clinic, Department of Biomorphological Sciences, University of Messina, 98124 Messina, Italy
- Ophthalmology Section, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Kraków, Poland
| | - Joanna Kokot
- Ophthalmology Department, Railway Hospital, 40-760 Katowice, Poland
- Chair and Clinical Department of Ophthalmology, II School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, 40-760 Katowice, Poland
| | - Dariusz Dobrowolski
- Ophthalmology Department, Railway Hospital, 40-760 Katowice, Poland
- Chair and Clinical Department of Ophthalmology, II School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, 40-760 Katowice, Poland
- Ophthalmology Clinic of St. Barbara Hospital, 42-200 Sosnowiec, Poland
| | - Edward Wylęgała
- Ophthalmology Department, Railway Hospital, 40-760 Katowice, Poland
- Chair and Clinical Department of Ophthalmology, II School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, 40-760 Katowice, Poland
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Clear Cornea Femto DALK: a novel technique for performing deep anterior lamellar keratoplasty. Graefes Arch Clin Exp Ophthalmol 2022; 260:2941-2948. [PMID: 35380269 DOI: 10.1007/s00417-022-05582-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/04/2022] Open
Abstract
PURPOSE A new femtosecond laser assisted deep anterior lamellar keratoplasty technique (Clear Cornea Femto DALK or CCF DALK) can be performed with less technical challenges compared to conventional procedures. This paper reports on a preliminary case series to evaluate the technique. METHOD First, through a clear cornea approach, Descemet's membrane (DM) is completely separated from posterior stroma by injection of balanced salt solution/viscoelastic substance through a special cannula inserted into the deep stroma and positioned right above the DM without perforating. The injection creates a liquid chamber that detaches the DM while preserving a reasonably transparent corneal stroma. Afterwards, a complete posterior/anterior trephination of the stroma, from the liquid chamber to the epithelium, is done using a femtosecond laser system under optical coherence tomography control. RESULTS This technique was successfully performed in a preliminary series of 10 eyes/10 patients. All patients had the DM completely bared and kept their own endothelial cell population with minimal cell loss (< 15%) after 6 months. Postoperative interface reaction was minimal, and no immune reactions were observed thus far. CONCLUSION Clear Cornea Femto DALK is a promising alternative to previous Femto DALK procedures with good acceptance of the tissue seen to date.
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An Overview of Intraoperative OCT-Assisted Lamellar Corneal Transplants: A Game Changer? Diagnostics (Basel) 2022; 12:diagnostics12030727. [PMID: 35328280 PMCID: PMC8947300 DOI: 10.3390/diagnostics12030727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 02/01/2023] Open
Abstract
Intraoperative optical coherence tomography (iOCT) is a noninvasive imaging technique that gives real-time dynamic feedback on surgical procedures. iOCT was first employed in vitreoretinal surgery, but successively served as a guidance in several anterior segment surgical approaches: keratoplasty, implantable Collamer lens (ICL) implantation, and cataract surgery. Among all of those approaches, the unbeatable features of iOCT are fully exploited in anterior and posterior lamellar keratoplasty, and the purpose of this review is to focus on the advantages and shortfalls of iOCT in these techniques, in order to assess whether this technology could be a real step forward. In deep anterior lamellar keratoplasty (DALK), iOCT is useful to evaluate the needle depth into the corneal stroma, the big bubble dissection plane, and residual stromal bed, thus aiding the standardization of the technique and the reduction of failures. In Descemet stripping automated endothelial keratoplasty (DSAEK), iOCT allowed for clear visibility of fluid at the graft/host interface, allowing for immediate rescue maneuvers and granting the best graft apposition. In Descemet membrane endothelial keratoplasty (DMEK), iOCT can track the lenticule unfolding in real time and assess graft orientation even in severe hazy corneas, thus optimizing surgical times, as well as avoiding the use of potentially hazardous exterior markers (such as the “S” stamp) and preventing unnecessary manipulation of the graft. Overall, the role of iOCT appeared crucial in several complicated cases, overcoming the difficulties of poor visualization in a fast, non-invasive way, thus raising this approach as possible gold standard for challenging conditions. Further improvements in the technology may enable autonomous centering and tracking, overcoming the current constraint of instrument-induced shadowing.
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Femtosecond laser-assisted big bubble for deep anterior lamellar keratoplasty. J Cataract Refract Surg 2021; 47:106-110. [PMID: 32932372 DOI: 10.1097/j.jcrs.0000000000000400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/11/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the utility of a femtosecond laser-assisted stromal channel to assist the creation of a big bubble (BB) for deep anterior lamellar keratoplasty (DALK) surgery in cadaveric corneas. SETTING L V Prasad Eye Institute, Hyderabad, India. DESIGN Experimental study. METHODS An attempt to create a BB was made on 10 donor pairs of human cadaveric corneoscleral tissues. The 20 corneas were split into 2 groups: Group A underwent femtosecond laser pretreatment and Group B had conventional manual deep lamellar technique. Laser pretreatment was performed using the VisuMax femtosecond laser system to create a stromal channel using the intracorneal ring segment treatment module for direct insertion of the 27-gauge air cannula for pneumodissection at a predetermined depth. RESULTS Of the 20 corneas studied, type 1 BB was achieved in 9 of 10 corneas in Group A and in 7 of 10 corneas in Group B. One cornea from Group A had a combined type 1 and 2 BB, whereas no BB was achieved in 1 cornea. CONCLUSIONS Creation of an intrastromal channel using a femtosecond laser at a predetermined depth seemed to be a promising option to increase the chances of achieving a BB when compared with the conventional air injection technique of BB DALK.
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Deshmukh R, Stevenson LJ, Vajpayee RB. Laser-assisted corneal transplantation surgery. Surv Ophthalmol 2021; 66:826-837. [PMID: 33524460 DOI: 10.1016/j.survophthal.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/01/2022]
Abstract
Corneal transplant surgeries have a broad range of indications with outcomes largely dependent on surgeon experience. Traditional manual techniques have certain limitations pertaining to the preparation of donor tissue and the recipient bed that might affect the predictability of visual outcomes. Use of lasers for keratoplasty procedures not only improves the repeatability and consistency of the technique, but also enables the surgeon to control the thickness and shape of the transplant tissue tailored to the specific condition. Despite the advantages, cost-effectiveness and technical know-how remain the major challenges. We discuss the various techniques of laser-assisted keratoplasties with respect to their methods, precision, and efficacy in various corneal indications.
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Affiliation(s)
- Rashmi Deshmukh
- Division of Ophthalmology and Visual Sciences, Eye ENT Centre, Queens Medical Centre, University of Nottingham, UK.
| | | | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Vision Eye Institute, Melbourne, Australia; University of Melbourne, Australia
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Femtosecond-Laser Assisted Surgery of the Eye: Overview and Impact of the Low-Energy Concept. MICROMACHINES 2021; 12:mi12020122. [PMID: 33498878 PMCID: PMC7912418 DOI: 10.3390/mi12020122] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022]
Abstract
This article provides an overview of both established and innovative applications of femtosecond (fs)-laser-assisted surgical techniques in ophthalmology. Fs-laser technology is unique because it allows cutting tissue at very high precision inside the eye. Fs lasers are mainly used for surgery of the human cornea and lens. New areas of application in ophthalmology are on the horizon. The latest improvement is the high pulse frequency, low-energy concept; by enlarging the numerical aperture of the focusing optics, the pulse energy threshold for optical breakdown decreases, and cutting with practically no side effects is enabled.
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Comparison of the effects of femtosecond laser energy on corneal endothelium at two different dissection levels in femtosecond laser-assisted deep anterior lamellar keratoplasty for keratoconus. Int Ophthalmol 2021; 41:1167-1177. [PMID: 33398508 DOI: 10.1007/s10792-020-01669-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/27/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The objective of this study is to compare the endothelial safety of femtosecond laser (FSL) energy at two different dissection depths in FSL-assisted deep anterior lamellar keratoplasty (FSDALK) for keratoconus. METHODS This prospective double-armed interventional study included 25 eyes from 21 patients with advanced keratoconus who underwent FSDALK (big bubble technique) at a trephination depth of 110 µm in group I (11 eyes) and 80 µm in group II (14 eyes)-all of which were anterior to the Descemet's membrane (DM). Visual acuity measurement, anterior and posterior segment examination, corneal tomography, and specular microscopy were performed preoperatively and at 3, 6, and 12 months, postoperatively. Endothelial cell density, coefficient of variation, percentage of cell hexagonality, and pachymetry were used to evaluate endothelial safety. RESULTS No statistically significant difference in any of the endothelial safety parameters was found between the two groups. The mean 12-month postoperative endothelial cell loss rate was 17.46% and 12.91% in group I and II, respectively (P = 0.345). Most of the endothelial cell loss occurred during the first 3 months after surgery. Group II showed statistically greater improvement in the mean keratometry values at all follow-up visits. CONCLUSION The endothelial safety profiles of lamellar FSL cuts at 110 µm and 80 µm anterior to the DM are comparable. Cuts as deep as 80 µm anterior to the DM can be safely applied without causing significant injury to the endothelium. Further studies are needed to compare the endothelial safety profiles of different FSL platforms available in the market. Trial registration PACTR201901615323963. Registered 24 November 2018-retrospectively registered.
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Sharma N, Agarwal R, Jhanji V, Bhaskar S, Kamalakkannan P, Nischal KK. Lamellar keratoplasty in children. Surv Ophthalmol 2020; 65:675-690. [DOI: 10.1016/j.survophthal.2020.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023]
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Preliminary Results of a Novel Standardized Technique of Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty for Keratoconus. J Ophthalmol 2020; 2020:5496162. [PMID: 32963820 PMCID: PMC7491466 DOI: 10.1155/2020/5496162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/06/2020] [Accepted: 08/25/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the feasibility and the initial outcomes of a novel standardized surgical technique of femtosecond laser- (FSL-) assisted big-bubble deep anterior lamellar keratoplasty (BBDALK) for eyes with keratoconus. Methods This prospective interventional case series included 11 consecutive FSL-assisted BBDALK procedures performed for the eyes with keratoconus from September 2019 to December 2019. The FSL was used to create (i) an intrastromal channel incision (1.7 mm in length, 4.6 mm in width, 80% depth, and cut energy of 1.70 μJ) and (ii) a 9.0 mm diameter circular lamellar side cut 65 μm above the endothelium (cut energy of 0.90 μJ) intersecting the intrastromal incision. In the operating room, a blunt dissector was used to open the intrastromal channel incision, through which a blunt spatula was inserted, tangentially advanced towards the center of the cornea, and replaced with a blunt cannula for pneumatic dissection. The subsequent surgical steps did not differ from the conventional technique. Main outcome measures were the success rate of pneumatic dissection and the percentage of intraoperative complications. Results Eleven eyes of 11 patients (6 males and 5 females; mean age: 34.54 ± 13.23 years) underwent FSL-assisted DALK. Using the FSL, both corneal incisions (lamellar side cut and intrastromal channel incision) were successfully created in all cases without the need for repeat docking or additional dissection. Pneumatic dissection with type 1 bubble formation succeeded in all 11 eyes (100%). DALK surgery was completed uneventfully in all cases. Descemet membrane perforation did not occur in any case, and no procedure was converted to penetrating keratoplasty. Conclusion Using standardized FSL parameters for both incision design and cut energy in BBDALK surgery, pneumatic dissection can be achieved in a very high rate of cases with minimal risk of intraoperative complications.
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Coelho RP, Messias A. Phacoemulsification with big-bubble deep anterior lamellar keratoplasty: Variant of the triple procedure. J Cataract Refract Surg 2019; 45:1064-1066. [DOI: 10.1016/j.jcrs.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
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Abstract
PURPOSE OF REVIEW A survey of the recent literature of deep anterior lamellar keratoplasty using femtosecond laser technology. RECENT FINDINGS There are several recent reports in the literature assessing technique and outcomes of deep anterior lamellar keratoplasty done with a femtosecond laser trephination. Most of these reports are laboratory studies and small case series with short-term outcomes. The laser technology is expensive and may not produce better results than conventional manual techniques. However, there are several theoretical advantages to femtosecond laser incisions in deep anterior lamellar keratoplasty that should be explored, including possible increased success of Descemet's membrane separation from stroma during surgery as well as postsurgical astigmatism benefits, earlier suture removal, and increased wound strength and healing. SUMMARY Femtosecond laser trephination in the setting of DALK may improve the technique by decreasing the number of descemet's membrane ruptures and improving short-term and long-term outcomes as compared with manual techniques. However, there is no consensus on a standardized approach for wound design or postoperative management. The literature would benefit from a prospective randomized controlled trial.
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Hos D, Matthaei M, Bock F, Maruyama K, Notara M, Clahsen T, Hou Y, Le VNH, Salabarria AC, Horstmann J, Bachmann BO, Cursiefen C. Immune reactions after modern lamellar (DALK, DSAEK, DMEK) versus conventional penetrating corneal transplantation. Prog Retin Eye Res 2019; 73:100768. [PMID: 31279005 DOI: 10.1016/j.preteyeres.2019.07.001] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/12/2022]
Abstract
In the past decade, novel lamellar keratoplasty techniques such as Deep Anterior Lamellar Keratoplasty (DALK) for anterior keratoplasty and Descemet stripping automated endothelial keratoplasty (DSAEK)/Descemet membrane endothelial keratoplasty (DMEK) for posterior keratoplasty have been developed. DALK eliminates the possibility of endothelial allograft rejection, which is the main reason for graft failure after penetrating keratoplasty (PK). Compared to PK, the risk of endothelial graft rejection is significantly reduced after DSAEK/DMEK. Thus, with modern lamellar techniques, the clinical problem of endothelial graft rejection seems to be nearly solved in the low-risk situation. However, even with lamellar grafts there are epithelial, subepithelial and stromal immune reactions in DALK and endothelial immune reactions in DSAEK/DMEK, and not all keratoplasties can be performed in a lamellar fashion. Therefore, endothelial graft rejection in PK is still highly relevant, especially in the "high-risk" setting, where the cornea's (lymph)angiogenic and immune privilege is lost due to severe inflammation and pathological neovascularization. For these eyes, currently available treatment options are still unsatisfactory. In this review, we will describe currently used keratoplasty techniques, namely PK, DALK, DSAEK, and DMEK. We will summarize their indications, provide surgical descriptions, and comment on their complications and outcomes. Furthermore, we will give an overview on corneal transplant immunology. A specific focus will be placed on endothelial graft rejection and we will report on its incidence, clinical presentation, and current/future treatment and prevention options. Finally, we will speculate how the field of keratoplasty and prevention of corneal allograft rejection will develop in the future.
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Affiliation(s)
- Deniz Hos
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Mario Matthaei
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Felix Bock
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Kazuichi Maruyama
- Department of Innovative Visual Science, Graduate School of Medicine, Osaka University, Japan
| | - Maria Notara
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Thomas Clahsen
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Yanhong Hou
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Viet Nhat Hung Le
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Department of Ophthalmology, Hue College of Medicine and Pharmacy, Hue University, Viet Nam
| | | | - Jens Horstmann
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Bjoern O Bachmann
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Claus Cursiefen
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.
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Intraoperative Optical Coherence Tomography-Guided Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty. Cornea 2019; 38:648-653. [PMID: 30614905 DOI: 10.1097/ico.0000000000001851] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe the feasibility and outcomes of intraoperative optical coherence tomography (OCT)-guided, femtosecond laser-assisted deep anterior lamellar keratoplasty in which the lamellar and tunnel cuts were completed by laser. METHODS The Ziemer Z8 system was used to scan the corneas intraoperatively and guide the stromal lamellar and tunnel cuts created by the laser. Thirty porcine eyes and 3 human cadaver globes were used to evaluate the accuracy of laser-created intrastromal tunnels and the feasibility of achieving big-bubble pneumatic dissection. The tunnel distance above the Descemet membrane (Dt-dm) was set at 100 and 130 μm, and the accuracy of laser cut was assessed by anterior segment OCT and histological sections. Fourteen patients with keratoconus or corneal scars were then included to evaluate the clinical outcomes. RESULTS The deviation from the targeted Dt-dm was 5.5% to 8.6% and 0.7% to 9.8% for the 100 and 130 μm groups, respectively. The achieved thickness had a significantly and positively strong correlation with the targeted thickness (r = 0.86; P < 0.001). In all cases, the anterior stromal lamella was removed without difficulty, except in the patients with corneal scars in whom some remaining stromal fiber attachments were observed. A type 1 big bubble was successfully achieved in all patients. CONCLUSIONS We present the accuracy and clinical outcomes of femtosecond laser-assisted, intraoperative OCT-guided deep anterior lamellar keratoplasty, in which controlled lamellar and tunnel cuts at desired depths were performed by laser in one step, and a successful big bubble was achieved.
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Buzzonetti L, Petrocelli G, Valente P, Petroni S, Parrilla R, Iarossi G. Refractive outcome of keratoconus treated by big-bubble deep anterior lamellar keratoplasty in pediatric patients: two-year follow-up comparison between mechanical trephine and femtosecond laser assisted techniques. EYE AND VISION 2019; 6:1. [PMID: 30656177 PMCID: PMC6330749 DOI: 10.1186/s40662-018-0127-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 12/22/2018] [Indexed: 11/24/2022]
Abstract
Background To evaluate refractive outcome 24 months after Deep Anterior Lamellar Keratoplasty (DALK) in pediatric patients by comparing results achieved using mechanical trephine and femtosecond laser. Methods Twenty eyes of 20 patients affected by keratoconus were evaluated. To perform big-bubble DALK, 10 eyes (Group 1; mean age 11.2 ± 2.2 years) were subjected to the Hessburg-Barron mechanical trephine and the remaining 10 eyes (Group 2; mean age 11.3 ± 3.1 years) to a 150 kHz femtosecond laser that performed mushroom incisions. Preoperative thinnest point in the corneal thickness map and K readings were measured by the Sirius Scheimpflug camera. We also evaluated corrected distance visual acuity (CDVA) as logMAR value using spectacles, spherical equivalent and refractive astigmatism. Results Mean preoperative thinnest point and pre- and post-operative K readings did not show significant difference (P > 0.05) between the two groups. CDVA, spherical equivalent and refractive astigmatism were respectively, 0.14 ± 0.08 logMAR and 0.13 ± 0.10 logMAR (P = 0.8), − 4.2 ± 1.1 D and − 2.8 ± 1.2 D (P = 0.03), 4.4 ± 2.0 D and 3.6 ± 1.2 D (P = 0.4) in Groups 1 and 2. All DALK procedures were uneventful. Conclusion Our findings suggest that femtosecond laser compared to mechanical trephine could significantly reduce the spherical equivalent amount in pediatric big-bubble DALK.
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Affiliation(s)
- Luca Buzzonetti
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Gianni Petrocelli
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Paola Valente
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Sergio Petroni
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Rosa Parrilla
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Giancarlo Iarossi
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
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Abstract
Lamellar keratoplasty (LK) has revolutionized corneal graft surgery in several ways. Deep anterior LK (DALK) has eliminated risk of failure due to endothelial rejection. Endothelial keratoplasty (EK) has almost eliminated induced astigmatism and the “weak” graft–host junction as seen with penetrating keratoplasty (PK) and also reduced the risk of endothelial rejection. LK provided new insights into posterior corneal anatomy that led to better understanding and performance of DALK and to the development of another EK procedure, namely pre-Descemet's EK (PDEK). Surgical procedures for LK were further refined based on the improved understanding and are able to deliver better surgical outcomes in terms of structural integrity and long-term patient satisfaction, reducing the need of further surgeries and minimizing patient discomfort. In most specialist centers, anterior lamellar techniques like DALK and EK techniques like Descemet's stripping EK (DSEK) and Descemet's membrane EK (DMEK) have replaced the full-thickness PK where possible. The introduction of microkeratome, femtosecond laser, and PDEK clamp have made LK techniques easier and more predictable and have led to the innovation of another LK procedure, namely Bowman membrane transplant (BMT). In this article, we discuss the evolution of different surgical techniques, their principles, main outcomes, and limitations. To date, experience with BMT is limited, but DALK has become the gold standard for anterior LK. The EK procedures too have undergone a rapid transition from DSEK to DMEK and PDEK emerging as a viable option. Ultrathin-DSEK may still have a role in modern EK.
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Affiliation(s)
- Nadisha P Singh
- Division of Clinical Neuroscience, University of Nottingham, UK
| | - Dalia G Said
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust; Division of Clinical Neuroscience, University of Nottingham, UK
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Nanavaty MA, Vijjan KS, Yvon C. Deep anterior lamellar keratoplasty: A surgeon's guide. J Curr Ophthalmol 2018; 30:297-310. [PMID: 30555961 PMCID: PMC6276733 DOI: 10.1016/j.joco.2018.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 05/27/2018] [Accepted: 06/09/2018] [Indexed: 12/14/2022] Open
Abstract
Purpose To review and highlight important practical aspects of deep anterior lamellar keratoplasty (DALK) surgery and provide some useful tips for surgeons wishing to convert to this procedure from the conventional penetrating keratoplasty (PK) technique. Methods In this narrative review, the procedure of DALK is described in detail. Important pre, intra, and postoperative considerations are discussed with illustrative examples for better understanding. A comprehensive literature review was conducted in PubMed/Medline from January 1995 to July 2017 to identify original studies in English language regarding DALK. The primary endpoint of this review was the narrative description of surgical steps for DALK, its pitfalls, and management of common intraoperative complications. Results A standard DALK procedure can be successfully performed taking into consideration factors such as age, ophthalmic co-morbidities, status of the crystalline lens, retina, and intraocular pressure. Careful trephination and dissection of the host cornea employing appropriate technique (such as big bubble technique, manual dissection, visco-dissection, etc.) suitable for the specific case is important to achieve good postoperative outcomes. Prompt identification of intraoperative complications such as double bubble, micro and macroperforations, etc. are vital to change the management strategies. Conclusion Although there is a steep learning curve for DALK procedure, considering details and having insight into the management of intraoperative issues facilitates learning and reduces complication rates.
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Affiliation(s)
- Mayank A Nanavaty
- Sussex Eye Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Kanwaldeep Singh Vijjan
- Sussex Eye Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Camille Yvon
- Sussex Eye Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom
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20
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Guindolet D, Nguyen DT, Bergin C, Doan S, Cochereau I, Gabison EE. Double-Docking Technique for Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty. Cornea 2018; 37:123-126. [PMID: 29095752 DOI: 10.1097/ico.0000000000001442] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe a new and safe surgical technique of deep anterior lamellar keratoplasty (DALK) using the femtosecond laser (FSL) and intraoperative optical coherence tomography (iOCT) for surgical management of corneal thinning and/or opacities. The technique was coined the double-docking procedure for DALK (DD-DALK). METHODS FSL-integrated iOCT was used for direct visualization and calibration to perform precise anterior lamellar and side cuts for the removal of the anterior stroma. Air was then injected in the residual posterior stroma to detach Descemet membrane [big-bubble (BB) formation]. Returning the residual posterior stroma into the docked position, a cylindrical vertical cut was made with the FSL to securely open the BB roof. Next, the stromal roof of the BB was removed with forceps leaving Descemet membrane intact, followed by a lamellar corneal graft. RESULTS Anterior stroma resection, BB formation, and residual stromal resection were achieved in every case without perforation. The curved applanation surface helped to limit the formation of folds on the posterior stroma (ie, advanced thinning). CONCLUSIONS DD-DALK is a reproducible and safe procedure for surgical management of corneal thinning and/or opacities. The precision of stromal cuts made by the FSL and iOCT guidance for air injection increases success in DD-DALK preparation.
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Affiliation(s)
- Damien Guindolet
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France
| | - Diem T Nguyen
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France
| | | | - Serge Doan
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France
| | - Isabelle Cochereau
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France.,Université Paris Diderot, Sorbonne Paris Cite[Combining Acute Accent], France
| | - Eric E Gabison
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France.,Université Paris Diderot, Sorbonne Paris Cite[Combining Acute Accent], France
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22
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Maharana PK, Sahay P, Singhal D, Garg I, Titiyal JS, Sharma N. Component corneal surgery: An update. Indian J Ophthalmol 2017; 65:658-672. [PMID: 28820150 PMCID: PMC5598175 DOI: 10.4103/ijo.ijo_582_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Several decades ago, penetrating keratoplasty was a challenge to corneal surgeons. Constant effort by the corneal surgeon to improve the outcomes as well as utilization of the available resources has led to a revolutionary change in the field of keratoplasty. All these efforts have led to the evolution of techniques that allow a corneal surgeon to disease-specific transplant of individual layers of corneal “so-called component corneal surgery” depending on the layer of cornea affected. This has led to an improvement in corneal graft survival as well as a better utilization of corneal tissues. This article reviews the currently available literature on component corneal surgeries and provides an update on the available techniques.
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Affiliation(s)
- Prafulla K Maharana
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Pranita Sahay
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Deepali Singhal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Itika Garg
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jeewan S Titiyal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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[Comparison of anatomic and functional results between Z6 femtosecond laser assisted and manual trephination in deep anterior lamellar keratoplasty for advanced keratoconus [French version]]. J Fr Ophtalmol 2017; 40:571-579. [PMID: 28844326 DOI: 10.1016/j.jfo.2017.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 01/22/2017] [Accepted: 01/24/2017] [Indexed: 11/20/2022]
Abstract
The management of severe keratoconus requires corneal transplantation, for which the gold standard is deep anterior lamellar keratoplasty (DALK), preserving the healthy Descemet's membrane and endothelium. The safety and reproducibility of corneal cuts have been improved by the evolution of femtosecond lasers in refractive surgery, and femtosecond laser in DALK would seem to provide the same advantages over the manual method. In our retrospective study, we compare functional and anatomical results of femtosecond assisted DALK versus manual trephination DALK in patients with keratoconus in stage 4 of the Krumeich classification. It is a retrospective study including all patients with stage 4 keratoconus who underwent femtosecond laser assisted DALK between November 2012 and November 2015 in Nantes hospital. We compared those patients to a group of patients who underwent manual DALK in the same period, paired by age and maximal keratometry. We assessed visual acuity, pachymetry, endothelial cell density (specular microscopy), and keratometry before surgery and at 4, 8 and 12 months of follow-up. Laser settings and intraoperative complications were recorded. Nineteen patients underwent surgery by femtosecond assisted DALK, 6 women and 12 men with average age 30.2±10.8 years at transplantation. They were paired with a group of 17 patients who underwent manual DALK in order to compare results. Before surgery, mean visual acuity in the femtosecond group was 0.90 logMAR versus 0.89 logMAR in the manual group, showing no statistically significant difference (P=0.96). Both groups were similar in terms of preoperative age, mean keratometry, pachymetry and endothelial cell density. Average visual acuity post-surgery was 0.27, 0.26; and 0.14 logMAR for femtosecond DALK versus 0.27, 0.17 et 0.25 for manual DALK at 4, 8 and 12 months follow-up, respectively showing no statistically significant difference. After surgery, at 4, 8 and 12 months, mean pachymetry was similar in both groups, and average endothelial cell density was 2390 cells/mm2 in femtoDALK versus 2531 cells/mm2 in manual DALK at 12 months of follow-up, showing no statistically significant difference (P=0.5726). The rate of Descemet's membrane microperforations during the procedure was low and similar for both groups. Our study allows for a 12 month follow-up, with assessment of visual recovery, anatomical result and endothelial safety in a sample of 19 femtosecond laser assisted DALK with no statistical significant difference versus the manual trephination group. Femtosecond laser allows for increased reproducibility of the DALK procedure without reducing adverse effects during surgery. Femtosecond laser seems to improve the technique of the DALK procedure, and future developments could improve the reproducibility of DALK even further. A medical economics study would be necessary to determine the cost effectiveness of femtosecond laser assisted DALK.
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Lu Y, Chen X, Yang L, Xue C, Huang Z. Femtosecond laser-assisted deep anterior lamellar keratoplasty with big-bubble technique for keratoconus. Indian J Ophthalmol 2017; 64:639-642. [PMID: 27853010 PMCID: PMC5151152 DOI: 10.4103/0301-4738.194326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose: The purpose of this study was to evaluate the clinical results after deep anterior lamellar keratoplasty (DALK) assisted by the femtosecond laser with big-bubble technique for keratoconus. Methods: A case series of 22 eyes in 19 patients with keratoconus was enrolled in the study. The 500-kHz VisuMax femtosecond laser (Carl Zeiss Meditec AG, Jena, Germany) was used to create a vertical side cut on donor and recipient corneas. Intraoperative and postoperative complications, uncorrected visual acuity, best-corrected visual acuity, corneal curvature, and central corneal thickness were evaluated in all patients. Results: Big-bubble and naked Descemet's membrane (DM) were successfully achieved in twenty eyes (90.9%). Intraoperative macroperforation of DM occurred in two cases and converted to full-thickness keratoplasty. The mean follow-up time was 18.8 ± 5.3 months. The best-corrected visual acuity was increased from 0.3 to 1.0, mean corneal curvature was 43.0 ± 2.3D, and mean central corneal thickness was 508.9 ± 60.1 μm (range, from 430 to 600 μm) postoperatively. Conclusion: Our results indicate that femtosecond laser-assisted DALK with big-bubble technique is an accurate, safe, and effective method to treat the patients with keratoconus.
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Affiliation(s)
- Yan Lu
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Xiangfei Chen
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University; Department of Endocrinology, Geriatric Research Center, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Liping Yang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Chunyan Xue
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Zhenping Huang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
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Blériot A, Martin E, Lebranchu P, Zimmerman K, Libeau L, Weber M, Vabres B, Orignac I. Comparison of 12-month anatomic and functional results between Z6 femtosecond laser-assisted and manual trephination in deep anterior lamellar keratoplasty for advanced keratoconus. J Fr Ophtalmol 2017; 40:e193-e200. [PMID: 28601345 DOI: 10.1016/j.jfo.2017.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 04/23/2017] [Accepted: 05/02/2017] [Indexed: 11/19/2022]
Abstract
The management of severe keratoconus requires corneal transplantation, for which the gold standard is deep anterior lamellar keratoplasty (DALK), preserving the healthy Descemet's membrane and endothelium. The safety and reproducibility of corneal cuts have been improved by the evolution of femtosecond lasers in refractive surgery, and femtosecond laser in DALK would seem to provide the same advantages over the manual method. In our retrospective study, we compare functional and anatomical results of femtosecond-assisted DALK versus manual trephination DALK in patients with keratoconus in stage 4 of the Krumeich classification. It is a retrospective study including all patients with stage 4 keratoconus who underwent femtosecond laser-assisted DALK between November 2012 and November 2015 in Nantes university medical center. We compared those patients to a group of patients who underwent manual DALK in the same period, paired by age and maximal keratometry. We assessed visual acuity, pachymetry, endothelial cell density (specular microscopy), and keratometry before surgery and at 4, 8 and 12 months of follow-up. Laser settings and intraoperative complications were recorded. Nineteen patients underwent surgery by femtosecond-assisted DALK, 6 women and 12 men with average age 30.2±10.8 years at transplantation. They were paired with a group of 17 patients who underwent manual DALK in order to compare results. Before surgery, mean visual acuity in the femtosecond group was 0.90 logMAR versus 0.89 logMAR in the manual group, showing no statistically significant difference (P=0.96). Both groups were similar in terms of preoperative age, mean keratometry, pachymetry and endothelial cell density. Average visual acuity post-surgery was 0.27; 0.26; and 0.14 logMAR for femtosecond DALK versus 0.27; 0.17 et 0.25 for manual DALK at 4, 8 and 12 months follow-up respectively, showing no statistically significant difference. After surgery, at 4, 8 and 12 months, mean pachymetry was similar in both groups, and average endothelial cell density was 2390 cells/mm2 for femto DALK versus 2531 cells/mm2 for manual DALK at 12 months of follow-up, showing no statistically significant difference (P=0.5726). The rate of Descemet's membrane microperforations during the procedure was low and similar for both groups. Our study allows for a 12-month follow-up, with assessment of visual recovery, anatomic result and endothelial safety in a series of 19 femtosecond laser-assisted DALK with no statistical significant difference versus the manual trephination group. Femtosecond laser allows for increased reproducibility of the DALK procedure without reducing adverse effects during surgery. Femtosecond laser seems to improve the technique of the DALK procedure, and future developments could improve the reproducibility of DALK even further. A medical economics study would be necessary to determine the cost-effectiveness of femtosecond laser-assisted DALK.
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Affiliation(s)
- A Blériot
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - E Martin
- Ophthalmology service, Saint-Nazaire medical center, cité sanitaire Georges-Charpak, 11, boulevard Georges-Charpak, BP 414, 44606 Saint-Nazaire, France
| | - P Lebranchu
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - K Zimmerman
- MEDICARE-HTM, 3, rue Alain-Bombard, 44800 Saint-Herblain, France
| | - L Libeau
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Weber
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - B Vabres
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - I Orignac
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Cursiefen C, Schaub F, Bachmann B. [Update: Deep anterior lamellar keratoplasty (DALK) for keratoconus. When, how and why]. Ophthalmologe 2017; 113:204-12. [PMID: 26832733 DOI: 10.1007/s00347-015-0204-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The treatment of keratoconus has been significantly expanded in recent years. In addition to the previous options for correction by fitting hard contact lenses and penetrating keratoplasty (PK), corneal cross-linking and lamellar transplantation techniques have been added. OBJECTIVE The aim of this review article is to highlight currently available options for minimization of complications and standardization of deep anterior lamellar keratoplasty (DALK) for keratoconus. MATERIAL AND METHODS This article summarizes our own data and gives a review of the literature in PubMed. RESULTS Performing DALK can provide keratoconus patients with corneal grafts with considerably longer graft survival and a reduced risk of complications. CONCLUSION The DALK procedure provides numerous advantages over PK, especially the reduced intraoperative opening of the eye, which thus reduces the risk of serious intraoperative complications. A further benefit is the complete absence of postoperative endothelial immune reactions as the recipient's endothelium remains untouched. The absence of endothelial immune reactions is especially advantageous for young patients with keratoconus and patients with an increased risk of graft rejection, e.g. in atopic dermatitis; however, there are also typical complications of DALK that do not occur during PK. The outlined strategies for standardization of DALK and avoidance of intraoperative and postoperative complications should make DALK safer and more reproducible and lead to possible establishment as a standard procedure in keratokonus.
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Affiliation(s)
- C Cursiefen
- Zentrum für Augenheilkunde, Universität zu Köln, Universitätsklinikum Köln, Kerpener Straße 62, 50924, Köln, Deutschland
| | - F Schaub
- Zentrum für Augenheilkunde, Universität zu Köln, Universitätsklinikum Köln, Kerpener Straße 62, 50924, Köln, Deutschland.
| | - B Bachmann
- Zentrum für Augenheilkunde, Universität zu Köln, Universitätsklinikum Köln, Kerpener Straße 62, 50924, Köln, Deutschland
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Abstract
In recent years, there has been a considerable interest regarding the concept of lamellar keratoplasty (LK), which contributed in spreading the use of this procedure in the treatment of keratoconus. This is a new frontier in corneal surgery that minimizes trauma on the recipient patient since it works on a "closed bulb". The LK surgery, in fact, aims to selectively replace diseased corneal stroma, leaving the healthy endothelium. The main advantage of LK is to avoid major causes of failure of penetrating keratoplasty as immunological rejection, and the late mismatch in the transplanted cornea, thus increasing the life of transplantation. In the last decade, several techniques of LK have been proposed, depending on how the anterior portion of the recipient cornea is removed. This article, through a literary research reviews the various emerging techniques of anterior lamellar surgery for the management of keratoconus, analyzing their indications, visual outcomes, and rate of complications.
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Affiliation(s)
- Leopoldo Spadea
- Department of Biotechnology and Medical Surgical Sciences, Sapienza University of Rome, Latina, Italy. E-mail.
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Feizi S, Javadi MA, Fekri Y. Use of deep anterior lamellar keratoplasty (DALK) for keratoconus: indications, techniques and outcomes. EXPERT REVIEW OF OPHTHALMOLOGY 2016. [DOI: 10.1080/17469899.2016.1222904] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Big-bubble deep anterior lamellar keratoplasty using central vs peripheral air injection: a clinical trial. Eur J Ophthalmol 2016; 26:297-302. [PMID: 26541103 DOI: 10.5301/ejo.5000702] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare 2 sites of air injection to achieve Descemet membrane (DM) detachment in big-bubble deep anterior lamellar keratoplasty (DALK). METHODS In this prospective, randomized study, 48 eyes of 48 keratoconus-affected patients who underwent DALK by cornea fellows were enrolled. Each patient was randomly assigned into one of 2 groups. After trephination to approximately 80% of the corneal thickness, a 27-G needle was inserted into the stroma from the trephination site. The needle was moved radially inside the trephination site and advanced to the central or paracentral cornea in group 1. In group 2, the needle was inserted into the deep stroma from the trephination site and advanced into the peripheral cornea to approximately 1.5 mm anterior to the limbus. Air was gently injected into the deep stroma until a big bubble was formed. The rates of DM separation and complications were compared between the 2 groups. RESULTS Big-bubble formation was successful in 79.2% of the eyes in the study group. A bare DM was achieved by central injection in 68.0% of group 1 and by peripheral injection in 69.6% of group 2 (p = 0.68). This rate was increased to 80.0% and 78.3% in groups 1 and 2, respectively, after the injection site was shifted when injections failed. The study groups were comparable in terms of complications including DM perforation and bubble bursting. CONCLUSIONS Both injection sites were equivalent in their rates of big-bubble formation and complications. Less experienced surgeons are advised to initially inject air outside the trephination.
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Red Reflex-Guided Big-Bubble Deep Anterior Lamellar Keratoplasty: A Simple Technique to Judge Dissection Depth. Cornea 2016. [PMID: 26203751 DOI: 10.1097/ico.0000000000000497] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the results of a modified big-bubble deep anterior lamellar keratoplasty technique using the intraoperative red reflex to visualize the amount of residual stroma beneath the inserted cannula. METHODS A total of 132 consecutive keratoconic eyes were included in this retrospective, noncomparative, interventional case series. Before starting surgery, pharmacologic mydriasis was induced in all eyes undergoing a big-bubble deep anterior lamellar keratoplasty procedure. After partial trephination of the recipient cornea, a spatula was inserted at the base of the incision and advanced into depth using as a reference the thin dark line seen in the red reflex ahead of the advancing tip; the stromal depth reached was measured using anterior segment optical coherence tomography. Finally, the spatula was exchanged for a 27-gauge cannula, and air was injected to create a big bubble. The stromal depth reached with the spatula, success rate of big-bubble formation, and complications were recorded. RESULTS The big bubble was obtained in 118 of 132 eyes (89.4%). Of the remaining 14 eyes, 11 underwent completion of the procedure by manual dissection and 3 were converted to penetrating keratoplasty because the bubble burst while trying to enlarge it. Perforation did not occur in any case during cannula insertion. The average thickness reached with the stromal dissection was 64.3 ± 19.5 μm. CONCLUSIONS The thin dark line, seen in the red reflex obtained with pharmacologic dilation, provides a useful and effective reference that can be used to visualize and judge the depth of dissection, thus allowing a safer and reproducible approach to the pre-Descemetic stroma.
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Fung SSM, Aiello F, Maurino V. Outcomes of femtosecond laser-assisted mushroom-configuration keratoplasty in advanced keratoconus. Eye (Lond) 2016; 30:553-61. [PMID: 26795410 DOI: 10.1038/eye.2015.273] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 11/13/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the long-term outcomes after femtosecond laser (FSL)-assisted mushroom-configuration keratoplasty in advanced keratoconus. PATIENTS AND METHODS Thirteen eyes with Amsler-Krumeich stage IV keratoconus underwent FSL-assisted mushroom-configuration penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) at a tertiary referral centre. Preoperative risk factors included low orneal thickness, high keratometry measurements, previous hydrops, and central stromal scarring. Main outcome measures were visual acuity and refractive outcome. RESULTS The median follow-up was 33 months (range: 4-43). Preoperatively, the mean corrected distance visual acuity (CDVA) was 1.22±0.47 LogMAR (range: 0.5-1.9 LogMAR), mean minimum corneal thickness was 282±100.8 μm (range: 147-478 μm), and mean average keratometric (K) value was 63.4±7.63 dioptre (D; range: 57.0-75.7 D). Four patients underwent PKP and nine underwent DALK (two converted to PKP). Five patients subsequently underwent a modified arcuate mushroom interface dissection (AMID) procedure for astigmatic correction. At the final follow-up, the mean CDVA was 0.05±0.13 LogMAR (range: -0.10 to 0.20 LogMAR), mean spherical equivalent was -3.21±3.21D, mean cylindrical refractive error was 3.23±2.20 D, and mean average K was 43.1±1.53 D. Complications included early graft dehiscence, corneal vascularisation, stromal rejection, and sclerokeratitis. Sutures were completely removed at the mean 18.4 months for PKP and 9.1 months for DALK postoperatively. CONCLUSION FSL-assisted mushroom-configuration keratoplasty is feasible and safe in patients with stage IV keratoconus. AMID could further enhance the refractive outcome safely.
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Affiliation(s)
- S S M Fung
- Cornea and External Disease Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - F Aiello
- Cornea and External Disease Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Department of Experimental Medicine and Surgery, Ophthalmology Unit, University of Rome 'Tor Vergata', Rome, Italy
| | - V Maurino
- Cornea and External Disease Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Buzzonetti L, Petrocelli G, Valente P, Iarossi G, Ardia R, Petroni S, Parrilla R. The Big-Bubble Full Femtosecond Laser-Assisted Technique in Deep Anterior Lamellar Keratoplasty. J Refract Surg 2015; 31:830-4. [DOI: 10.3928/1081597x-20151111-07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/08/2015] [Indexed: 11/20/2022]
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Feizi S, Javadi MA, Daryabari SH. Factors influencing big-bubble formation during deep anterior lamellar keratoplasty in keratoconus. Br J Ophthalmol 2015; 100:622-5. [PMID: 26311063 DOI: 10.1136/bjophthalmol-2015-307111] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate recipient and operative factors that can influence the rate of achieving a bare Descemet's membrane (DM) during deep anterior lamellar keratoplasty (DALK) for keratoconus. MATERIALS In this retrospective comparative study, a total of 290 (153 right) consecutive eyes from 257 (179 male) keratoconus-affected patients who underwent DALK with the big-bubble technique were enrolled. Univariate analyses and multiple logistic regressions were used to investigate factors including patient age and sex, family history of keratoconus, history of contact lens wear or vernal keratoconjunctivitis, the presence of Vogt's striae or superficial stromal opacities, keratometric readings, corneal diameter, central and peripheral corneal thickness, anterior chamber depth, vitreous length, and trephination size, which could predict achievement of a bare DM. RESULTS The surgery was completed as a DALK in 289 of 290 eyes, and a bare DM was successfully achieved in 229 (79.2%) eyes. The recipient sex and trephination size significantly influenced the success rate of big-bubble formation. Females had decreased odds of achieving a bare DM by 0.44 times (p=0.02). For each 0.1 mm increase in the trephination size, the odds of a successful big-bubble formation increased by 1.36 times (p=0.03). Other investigated factors did not significantly influence the rate of achieving a bare DM. CONCLUSIONS The rate of successful big-bubble formation was 79.2% in keratoconus. Among the different factors, recipient sex and trephination size significantly influenced this rate. Females had a lower probability of big-bubble formation, and a large trephination size was associated with an increase in the probability of achieving a bare DM.
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Affiliation(s)
- Sepehr Feizi
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javadi
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed-Hashem Daryabari
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Maharana PK, Agarwal K, Jhanji V, Vajpayee RB. Deep Anterior Lamellar Keratoplasty for Keratoconus. Eye Contact Lens 2014; 40:382-9. [DOI: 10.1097/icl.0000000000000076] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Keane M, Coster D, Ziaei M, Williams K. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for treating keratoconus. Cochrane Database Syst Rev 2014; 2014:CD009700. [PMID: 25055058 PMCID: PMC10714035 DOI: 10.1002/14651858.cd009700.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Keratoconus is an ectatic (weakening) disease of the cornea, which is the clear surface at the front of the eye. Approximately 10% to 15% of patients diagnosed with keratoconus require corneal transplantation. This may be full-thickness (penetrating) or partial-thickness (lamellar). OBJECTIVES To compare visual outcomes after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty for keratoconus, and to compare additional outcomes relating to factors which may contribute to poor visual outcomes (e.g. astigmatism, graft rejection and failure). SEARCH METHODS We searched a number of electronic databases including CENTRAL, PubMed and EMBASE without using any date or language restrictions. We last searched the electronic databases on 31 October 2013. We also handsearched the proceedings of several international ophthalmic conferences. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing the outcomes of DALK and penetrating keratoplasty in the treatment of keratoconus. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data independently. For dichotomous data (graft failure, rejection, achievement of functional vision) results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs). For continuous data (postoperative best corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), keratometric astigmatism and spherical equivalent) results were expressed as mean differences (MDs) and 95% CIs. MAIN RESULTS We identified two completed studies, with a total of 111 participants (n = 30 and n = 81), both conducted in Iran, that met our inclusion criteria. Participants had moderate to severe keratoconus pre-operatively and were randomly allocated to receive either DALK or penetrating keratoplasty. Only one eye of each participant was treated as part of the trials. The smaller study had 12 month follow-up data for all participants. For the larger study, four DALK surgeries had to be abandoned due to technical failure and visual and refractive outcomes were not measured in these participants. Follow-up length for the remaining 77 participants ranged from 6.8 to 36.4 months, with all 77 followed for at least three months post-suture removal. Details of the randomisation procedure were unavailable for the smaller study and so sensitivity analyses were conducted to determine if the results from this study had affected the overall results of the review.Neither of the included studies reported a difference between groups on any of the measures of post-graft visual achievement, keratometric astigmatism or spherical equivalent. A single case of graft failure in a penetrating keratoplasty was reported. No postoperative graft failures were reported in the DALK group of either study.Instances of graft rejection were reported in both groups, in both studies. The majority of these cases were successfully treated with steroids. The data, which related to all cases in each study - given that the four cases that did not go ahead as planned had already technically failed without presence of rejection - showed that rejection was less likely to occur in DALK (odds ratio (OR): 0.33, 95% confidence interval (CI) 0.14 to 0.81, GRADE rating: moderate).Results of the sensitivity analysis indicated that inclusion of the Razmju 2011 study did not bias the results with regards to rejection episodes. While sensitivity analysis showed altered results with regards to failure rates, the data available from the Javadi 2010 study alone had a very wide 95% CI, suggesting an imprecise estimate. Therefore, even after removal of the Razmju 2011 data, it is still difficult to draw conclusions regarding superiority of one technique over another with regards to graft failure.DALK was unable to be completed as planned in four cases and in a further three cases, complications during dissection required further intervention. Other adverse events, of varying severity, were reported in both intervention groups with similar frequency. For both types of surgery, these included postoperative astigmatism, steroid induced ocular hypertension and persistent epithelial defects. In recipients of DALK, one participant had interface neovascularisation (a proliferation of blood vessels where the host and donor cornea come together) and one had wrinkling of Descemet's membrane, the basement membrane separating the corneal stroma from the corneal endothelium. In the penetrating keratoplasty groups, one participant required graft resuturing and one had an atonic pupil, a condition in which the pupil dilates and is non-reactive.Overall, the quality of the evidence was rated as very low to moderate, with methodological limitations, incomplete data analysis and imprecision of findings, as well as high risk of bias in several areas for both studies. AUTHORS' CONCLUSIONS We found no evidence to support a difference in outcomes with regards to BCVA at three months post-graft or at any of the other time points analysed (GRADE rating: very low). We also found no evidence of a difference in outcomes with regards to graft survival, final UCVA or keratometric outcomes. We found some evidence that rejection is more likely to occur following penetrating keratoplasty than DALK (GRADE rating: moderate). The small number of studies included in the review and methodological issues relating to the two, mean that the overall quality of the evidence in this review is low. There is currently insufficient evidence to determine which technique may offer better overall outcomes - final visual acuity and time to attain this, keratometric stabilisation, risk of rejection or failure, or both, and risk of other adverse events - for patients with keratoconus. Large randomised trials comparing the outcomes of penetrating keratoplasty and DALK in the treatment of keratoconus are needed.
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Affiliation(s)
- Miriam Keane
- Flinders UniversityDepartment of OphthalmologyLevel 3 Flinders Medical CentreBedford ParkAdelaideAustraliaSA 5042
| | - Douglas Coster
- Flinders UniversityDepartment of OphthalmologyLevel 3 Flinders Medical CentreBedford ParkAdelaideAustraliaSA 5042
| | - Mohammed Ziaei
- Moorfields Eye Hospital NHS Foundation Trust162 City RoadLondonUKEC1V 2PD
| | - Keryn Williams
- Flinders UniversityDepartment of OphthalmologyLevel 3 Flinders Medical CentreBedford ParkAdelaideAustraliaSA 5042
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Comparative study of corneal endothelial cell damage after femtosecond laser assisted deep stromal dissection. BIOMED RESEARCH INTERNATIONAL 2014; 2014:731565. [PMID: 25114918 PMCID: PMC4119749 DOI: 10.1155/2014/731565] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/24/2014] [Indexed: 11/17/2022]
Abstract
Purpose. To find a relatively safe designed stromal bed thickness to avoid endothelial damage for lamellar keratoplasty with an Allegretto Wavelight FS200 femtosecond laser. Methods. Twelve rabbits were randomly divided into 50 μm and 150 μm groups according to the anticipated residue stromal bed thickness preparation with a femtosecond laser. Six rabbits without laser cutting were used as a control group. Central endothelial images were analyzed with in vivo confocal microscopy and scanning electron microscopy. The apoptosis of endothelium was evaluated with Hoechst 33342 staining and a TUNEL assay. Results. The endothelium of the 50 μm group had extensive injuries upon in vivo confocal and scanning electron microscopic observation, and minor injuries were observed in the 150 μm group. Moreover, more apoptotic cells were observed in the 50 μm group. Conclusions. When using a FS200 femtosecond laser assisted anterior lamellar keratoplasty, there was minor endothelium damage with a 150 μm stromal bed, and a more than 150 μm thickness stromal bed design may prevent the damage of corneal endothelium.
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Deep anterior lamellar keratoplasty: surgical techniques, challenges, and management of intraoperative complications. Int Ophthalmol Clin 2013; 53:47-58. [PMID: 23470588 DOI: 10.1097/iio.0b013e31827eb746] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-Term Outcomes of Femtosecond Laser–Assisted Mushroom Configuration Deep Anterior Lamellar Keratoplasty. Cornea 2013; 32:390-5. [DOI: 10.1097/ico.0b013e318254a4e4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Arenas E, Esquenazi S, Anwar M, Terry M. Lamellar corneal transplantation. Surv Ophthalmol 2013; 57:510-29. [PMID: 23068974 DOI: 10.1016/j.survophthal.2012.01.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 01/24/2012] [Accepted: 01/27/2012] [Indexed: 11/29/2022]
Abstract
Penetrating keratoplasty (PK) has been the gold standard for the surgical treatment of most corneal pathologies; lamellar keratoplasty that only replaces the diseased corneal layers has recently evolved as an alternative, however. Innovations in surgical technique and instrumentation provide visual outcomes comparable to PK. We review the indications and outcomes of various techniques of anterior lamellar surgery developed to treat stromal disorders. Similarly, we discuss posterior lamellar keratoplasty techniques such as Descemet stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty. Posterior lamellar keratoplasty provides faster visual rehabilitation than PK in cases of Fuchs endothelial dystrophy and pseudophakic bullous keratopathy. In addition, for medically unresponsive infectious keratitis, therapeutic anterior lamellar keratoplasty yields similar graft survival to PK without an increased risk of disease recurrence.
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Scorcia V, Busin M, Lucisano A, Beltz J, Carta A, Scorcia G. Anterior segment optical coherence tomography-guided big-bubble technique. Ophthalmology 2012. [PMID: 23177365 DOI: 10.1016/j.ophtha.2012.08.041] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the feasibility of intraoperative anterior segment (AS) optical coherence tomography (OCT) for quantification of the corneal depth reached with the dissecting cannula used for deep anterior lamellar keratoplasty, as well as its correlation with the success rate of big-bubble formation. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS One hundred consecutive keratoconus patients. INTERVENTION Deep anterior lamellar keratoplasty was performed using the big-bubble technique. During surgery, the cannula used for pneumatic dissection was inserted into the peripheral stroma and advanced as deep and far toward the center as believed adequate by the surgeon. Then, after retracting the cannula, AS OCT was performed. The cannula was placed back in position and creation of the big bubble was attempted. MAIN OUTCOME MEASURES Stromal depth reached with the cannula tip, success rate in achieving big-bubble formation, and complication rate. RESULTS Bubble formation was obtained in 70 of 100 eyes (70%). In all remaining eyes, the procedure was completed by manual deep lamellar dissection. The average depth reached by the cannula tip was 104.3±34.1 μm from the internal corneal surface; the mean value recorded in cases of successful big-bubble formation (90.4±27.7 μm) was statistically lower than that measured in failed procedures (136.7±24.2 μm). In 1 case, corneal perforation occurred during the insertion of the cannula and required conversion to penetrating keratoplasty (PK). In 8 eyes, small microperforations occurred during stromal excision but could be managed conservatively, avoiding conversion to PK. In 2 advanced cones, an incomplete bubble formation was obtained, necessitating manual peripheral stromal removal. CONCLUSIONS Successful big-bubble formation can be anticipated if pneumatic dissection is attempted at a sufficiently deep level. Although an ideal depth could not be defined, AS OCT allows objective evaluation of the depth reached by the cannula tip used for pneumatic dissection. The AS OCT findings may confirm the decision to proceed with air injection. It is possible that cannula repositioning based on the AS OCT depth may improve the success rate for big-bubble formation.
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Affiliation(s)
- Vincenzo Scorcia
- Department of Ophthalmology, University of "Magna Graecia," Catanzaro, Italy.
| | - Massimo Busin
- Department of Ophthalmology, University of "Magna Graecia," Catanzaro, Italy; Department of Ophthalmology, Ospedale Privato "Villa Igea," Forlì, Italy; Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Andrea Lucisano
- Department of Ophthalmology, University of "Magna Graecia," Catanzaro, Italy
| | - Jacqueline Beltz
- Department of Ophthalmology, Ospedale Privato "Villa Igea," Forlì, Italy
| | - Arturo Carta
- Ophthalmology Section, University of Parma, Parma, Italy
| | - Giovanni Scorcia
- Department of Ophthalmology, University of "Magna Graecia," Catanzaro, Italy
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Pentacam-Based Big Bubble Deep Anterior Lamellar Keratoplasty in Patients with Keratoconus. Cornea 2012; 31:627-32. [DOI: 10.1097/ico.0b013e31823f8c85] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nita M, Strzałka-Mrozik B, Grzybowski A, Romaniuk W, Mazurek U. Ophthalmic transplantology: anterior segment of the eye - part I. Med Sci Monit 2012; 18:RA64-72. [PMID: 22534721 PMCID: PMC3560631 DOI: 10.12659/msm.882723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Transplantology is a quickly developing field of ophthalmology. It currently is able to treat many inherited, degenerative, inflammatory, traumatic, and cancerous diseases. This review outlines recent concepts and methods of treating ocular diseases with tissue and cell grafts. Ocular transplants related to the anterior part of the eye, including the conjunctiva and the cornea, are reviewed in Part 1. Material/Methods The scientific literature dated from January 2005 to July 2011 was thoroughly searched using Medline and PubMed. Publications dated 2009, 2010, and 2011 were analyzed in detail. Search terms were as follows: auto-, homo-, heterologous transplantation, eyeball, ocular adnexa, anterior segment of the eye, cornea, lamellar keratoplasty, stem cells, cultured cells. Further data were found at the website of the Eye Bank Association of America. Results Nearly all tissues of the anterior segment of the eye (the conjunctiva, sclera, eye muscles, and cornea) are transplanted. Because of the recent significant progress in the field, cornea transplantation was analyzed in more detail, specifically procedures such as limbus grafts and anterior and posterior lamellar keratoplasty. Indications, advantages, and drawbacks of the transplant techniques were also reviewed. Conclusions Recent progress in the field of cornea transplants allows treatment at the level of the endothelium and the use of cultured limbal epithelial stem cell grafts. However, compared with previous techniques, modern and multilayered transplant techniques of the cornea require much more expertise and longer training of the surgeon, as well as expensive and technologically advanced equipment. The availability of donor tissue is still the main limitation affecting all transplants. Therefore, cell culturing techniques such as stem cells, as well as artificial cornea projects, seem to be very promising.
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Affiliation(s)
- Małgorzata Nita
- Domestic and Specialized Medicine Centre Dilmed, Katowice, Poland
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Femtosecond laser and big-bubble deep anterior lamellar keratoplasty: a new chance. J Ophthalmol 2012; 2012:264590. [PMID: 22496960 PMCID: PMC3306993 DOI: 10.1155/2012/264590] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 10/30/2011] [Accepted: 11/08/2011] [Indexed: 11/17/2022] Open
Abstract
Purpose. To report the 12-month follow-up after big-bubble deep anterior lamellar keratoplasty (DALK) assisted by femtosecond laser that we have called IntraBubble. Methods. A 60 kHz IntraLase femtosecond laser (Abbott Medical Optics) firstly created a 30° angled intrastromal channel to insert the air injection cannula, 50 μ above the thinnest corneal site measured by Sirius Scheimpflug camera (CSO, Firenze, Italy), then performed a full lamellar cut 100 μ above the thinnest corneal point, and from the same corneal depth, created a mushroom incision. The lamella was removed, and the smooth cannula of Fogla was inserted into the stromal channel and air was injected to achieve a big bubble. The follow up is 12 months, and sutures were removed by the 10th postoperative month in all patients. Best Corrected Visual Acuity (BCVA), spherical equivalent and, by Sirius Scheimpflug camera (CSO, Firenze, Italy) keratometric astigmatism were evaluated. Results. All procedures were completed as DALK except 2 converted to PK because an inadvertent intraoperative macroperforation occurred. Mean postoperative BCVA was 0.8, mean spherical equivalent was -3.5 ± 1.7 D, and mean keratometric astigmatism was 4.8 ± 3.1 D. Conclusion. The femtosecond laser could standardize the big-bubble technique in DALK, reducing the risk of intraoperative complications and allowing good refractive outcomes.
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A Novel Mutation of the Decorin Gene Identified in a Korean Family With Congenital Hereditary Stromal Dystrophy. Cornea 2011; 30:1473-7. [DOI: 10.1097/ico.0b013e3182137788] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cursiefen C, Heindl L. Perspektiven der tiefen anterioren lamellären Keratoplastik. Ophthalmologe 2011; 108:833-9. [DOI: 10.1007/s00347-011-2331-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Birnbaum F, Maier P, Reinhard T. Perspektiven der Femtosekundenlaser-assistierten Keratoplastik. Ophthalmologe 2011; 108:807-16. [PMID: 21909868 DOI: 10.1007/s00347-011-2334-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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